Int J Ayu Pharm Chemijapc.com/volume9-second-issue/MNAPC-V9-I2-68-p-374-382.pdfShirodhara with ksheerabala tail (30 minutes each day) 3. Kala Basti (for 15 days) Anuvasana with Ksheerabala

Greentree Group Publishers

Received 07/08/18 Accepted 22/08/18 Published 10/09/18

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Sharma et al. 2018 Greentree Group Publishers © IJAPC Int J Ayu Pharm Chem 2018 Vol. 9 Issue 2 www.ijapc.com 374 [e ISSN 2350-0204]

Int J Ayu Pharm Chem CASE REPORT www.ijapc.com

e-ISSN 2350-0204

ABSTRACT

Spinocerebellar ataxias (SCAs) are a group of neurodegenerative disorders which affects the

cerebellum, mainly. There is no satisfactory treatment available for any of the over 30 known

causes of SCA till date. The present case study was conducted on a 31 years old male patient

already a diagnosed case of Sca (by AIIMS, New Delhi). He was managed according to the

line of treatment of vatavyadhi (group of neurological disorders) described in Ayurveda.

Panchakarma therapies like Abhyanga, Patra Pinda Pottali Swedana, Shirobasti, Shirodhara

and Kala/ Yoga basti were important therapies along with oral medicines. Patient’s condition

was assessed on the Scale for Assessment and Rating of Ataxia (SARA) which was reduced

from 21 to 6 after medication. Significant relief in symptoms was noted.

KEYWORDS

SCA, Panchakarma, Patra Pinda Pottali Sweda, Kala basti, Shirodhara, SARA

An Ayurvedic Approach to Spinocerebellar Ataxia-A Case

Report

Pushpa Sharma1*, Vishakha Wetal2 and Arun Gupta3 1-3PG department of Panchakarma, Chaudhary Brahm Prakash ayurved Charak Sansthan, Khera Dabar, New

Delhi, India

http://www.ijapc.com/

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Sharmaet al. 2018 Greentree Group Publishers© IJAPC Int J Ayu Pharm Chem 2018 Vol. 9 Issue 2 www.ijapc.com 375 [e ISSN 2350-0204]

INTRODUCTION

Spinocerebellar Ataxia (SCA) is a group of

progressive neurological disorders which

has common symptoms and disparate

genetic aetiology. The prevalence of SCA’s

is about 1-4/100,0001.

The common symptoms of SCAs include -

unsteady gait, uncoordinated limb

movements, and slurred speech which are

related to cerebellar dysfunction, but

individual SCAs have variable involvement

of extracerebellar areas. Polyglutamine

ataxias (SCAs 1, 2, 3, 6, 7, and 17) are the

diseases caused by an expanded CAG

repeat sequence and encode glutamine, in

the disease-causing gene 2. In these cases,

individuals can have similar repeat sizes but

age of disease onset, rate of disease

progression, and involvement of the

cerebellum and other areas of the nervous

system may differ for them3. SCA has a

tendency of anticipation which worsens

from generation to generation within a

family.

It is very difficult to develop treatments for

SCAs because delivery of gene targeting

strategies is obstacle and many disease-

causing mutations remain unknown. There

are only two reported Ayurvedic studies in

Pub Med indexed journals till date which

reports satisfactory improvement in

cerebellar ataxia4,5. Substantial recovery

was reported by the authors of the said

studies through Ayurvedic management.

This is important because no satisfactory

treatment is available for this genetic

disease.

CASE STUDY

A 31 years old male patient working as

taekwondo (Korean martial art) instructor

earlier; visited the Panchakarma OPD in

CBPACS, New Delhi in December 2016. It

was a known case of SCA under

supervision of Neuroscience centre,

AIIMS, New Delhi; although subtype of

SCA couldn’t be confirmed, but they

excluded the possibility of SCA1, 2, 3, 7 &

12. The patient was complaining of the

following symptoms:

1) Unsteady gait since 2 years and 6 months

2) Slurring of speech 1year and 2 months

3) Difficulty in balancing while sitting,

standing and walking since 2 years

4) Uncontrolled movements of both upper

limbs and other body parts since 1year

5) Graying of vision since 1 year

6) Involuntary eye movements since 1year

7) Difficulty in processing, learning and

remembering information since 2 years

8) Lower back ache since 1year

9) Intension tremors 1 year

10) Diminished facial expressions since

1year


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The symptoms had worsened progressively

over last one year. There was similar family

history in maternal grandfather, uncle and

siblings. The patient took medication from

various modern hospitals for one year, but

the condition was deteriorated. He was also

admitted in AIIMS, New Delhi on 9/5/16

for one week (UHID-10/633693), but no

significant improvement was noticed after

one year of treatment in AIIMS. So the

patient decided to approach ayurvedic

therapy. The case was planned for

Panchakarma (biopurification) therapy. He

was admitted in Panchakarma ward for 21

days initially.

Clinical Findings

The following were findings on physical

examination:

a) General

Pulse Rate: 92/min, regular, normal sinus

rhythm,Blood Pressure 100/70 mmHg

Temperature: Afebrile, Respiratory Rate:

16/ min.

No Pallor/icterus/cyanosis/clubbing/pedal

edema / palpable lymphadenopathy

b) Systemic

Per abdomen: Soft with no palpable

organomegaly/ mass, no shifting dullness,

bowel sounds were present

Respiratory & Cardiovascular System:

within normal limits

Central Nervous System: Conscious,

oriented, dysarthria present

Pupils normal sized, reacting to light

Normal gag reflex

No sensory loss/ parasthesias/ Seizures

Bilateral plantar reflexes- extensor

Bilateral reflexes- 3+, no clonus

No spasticity

Muscle power both limbs- within normal

limits

Nadi: Vata pitta

Mutra: Samyakpravritti

Mala:Constipated

Jiwha:Clear

Shabda:Not clear

Sparsha: Rough

Drik:Glaucoma present

Akriti:Anxious

Nidra:Alpa

Prikriti: Vatapaittik

Sara: Madhyam

Samhanan: Madhyam

Pramana:Sama

Satmya: Madhyam

Sattva: Madhyam

Agni: Vishamagni

Vyayama Shakti: Madhyam

Ahara Shakti: Madhyam

Jaran Shakti: Madhyam

Diagnostic Assessment

The case was already presented in AIIMS,

New Delhi where it was diagnosed as SCA,

but subtype couldn’t be confirmed due to

unavailability of genetic mapping. MRI

report was not available. The patient was


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having gadgadatva(impaired speech)

kampa(tremor), kalayakhanjata(Limping

with tremor), anidra(insomnia), purisa-

apravrtti(constipation),

paribhram(imbalance) etc. These

symptoms are mentioned in nanatamajvata

vyadhis6. Hence it was concluded to be

vatavyadhi as the Ayurvedic diagnosis

which is considered as asadhya(incurable).

Intervention

Considering the asadhya nature of the

disease, Ayurvedic treatment was planned

to alleviate the various symptoms and

complication of the disease. The treatment

is described in Table no.1.

All medicines except Brihatvatachintamani

were provided free to the patient from the

hospital; that’s why when a medicine was

not available other substitute was given

(like Trayodashanggug/ Yogarajguggulu,

Agnitundivati/ Ekangaveerras,

Ashwagandha/ Shatavari)

Niruhabasti was prepared as per classical

method described in text containing

Madhu(honey) 25gm,

Saindhavalavana(Rock salt) 5gm, Tila tail

(sesame oil) 50 ml, soya powder

(Foeniculum vulgare) 25gm and

RasnaErandadi kwatha 300 ml.

Follow‑up and outcomes

Patient’s condition was assessed on the

Scale for Assessement and Rating of Ataxia

(SARA)7 before admission, after 1st, 2nd and

3rd sitting of Panchakarma which was 21,

16, 12 and 6, respectively (Table no.2).

After 1st sitting of Panchakarma, the patient

was able to join his duty once again (That’s

why there was 5 months gap after 1st sitting

because it was a poor patient with no

financial support). There was significant

improvement in gait, speech & tremors,


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Table 1 Treatment plan for a case of SCA

Sitting 1st 2nd 3rd

D.O.A.(OPD/IP

D)

16/1/17 (130782/266) 29/6/17

(68109/3786)

29/8/17 (83326/5416)

Duration 21 days 15 days 10 days

Oral medicines 1. Trayodashanggug.

500mg twice a day with

lukewarm water

2. DashamoolaKwatha – 50 ml

twice a day

3. Agnitundivati 125mg thrice a

day with water

4. Brihatvatachintamani rasa-

125 mg twice a day with

honey

5.Ashwagandharista- 15 ml

twice a day after meal with

equal amount of water

1. Yogarajguggulu

500 mg twice a day

with lukewarm

water

2.

RasnaErandadiKwat

ha – 50 ml twice a

day

3.

BrihatVatachintama

ni rasa- 125 mg

twice a day with

honey

4. Shatavariguda-

5gm twice a day

with milk

1. Trayodashanggug.

500mg twice a day with

lukewarm water

2. DashamoolaKwatha – 50 ml

twice a day

3. Ekangveera rasa- 125 mg

thrice a day with water

4. Brihatvatachintamani rasa-

125 mg twice a day with honey

5. Ashwagandha Ch.-3 gm

along with muktashuktibhasm-

250 mg twice a day with milk

Panchakarma

Procedures

1. PPS with Dhanvantaram tail

(30 minutes each day)

2. Shirodhara with ksheerabala

tail (30 minutes each day)

3. Kala Basti (for 15 days)

Anuvasana with Ksheerabala

tail- 50 ml (after meal)

NiruhawithRasnaErandadikwa

tha- 300 ml (alternate days

empty stomach)

1. PPS with

Ksheerabala tail (30

minutes each day)

2. Shirobasti with

Dhanvantaram tail

(30 minutes each

day)

3. MatraBastiwith

Ksheerabala tail- 50

ml after meal (for 10

days)

1. PPS with Ksheerabala tail

(30 minites each)

2. Kati Basti with Panchaguna

tail (30 minutes each day)

3. Yoga Basti (for 8 days)

Anuvasana with Ksheerabala

tail- 50 ml (after meal)

NiruhawithRasnaErandadiKwa

tha- 300ml (alternate days

empty stomach)

*gug- Guggulu

* PPS- PatraPindaPottaliSwedana

Table 2 Assessment on the Basis Of SARA (Scale for Assessment and Rating of Ataxia )

S.

No.

Grading criteria Score before

admission

Score after 1st

sitting

Score after

2ndsitting

Score after

3rdsitting

1. Gait 3 2 2 1

2. Stance 4 3 2 1

3. Sitting 2 2 1 0

4. Speech

disturbance

3 2 2 1

5. Finger chase 2 1.5 1 0.5

6. Nose- finger test 3 2.5 2 1

7. Fast alternating

hand movements

2 1.5 1 0.5

8. Heel-shin slide 2 1.5 1 1

9. Total Score 21 16 12 6

autonomic dysfunctions were also

improved. Insomnia and constipation were

relieved. He was advised to continue

treatment for glaucoma from AIIMS. After

3rdsitting, the patient was instructed to

repeat Panchakarmatherapies at 3 months

interval for optimum relief.

Table No.2


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DISCUSSION

The dominantly inherited ataxias, now

called spinocerebellar ataxias (SCAs), are

progressive disorders in which the

cerebellum slowly degenerates, often

accompanied by degenerative changes in

the brainstem and other parts of the central

nervous system8. The patient was

diagnosed for Vatavyadhis as dhatuksaya is

the main causative factor and pathology in

the disease. The general line of treatment

for Nanatmajavatavyadhis was taken into

consideration for this case. Patient was

treated with Panchakarma therapies along

with oral medicines as discussed above

with significant relief.

Considering the Dhatukshaya, Santarpana

in the form of kalabasti /Matrabasti/Yoga

basti with Ksheerabalataila anuvasana,

Abhyanga&PatraPindaPottaliSwedan with

Dhanvantaram tail, Shirodhara with

Ksheerabala tail and Shirobastiwith

Dhanvantaramtaila was given. This

resulted in significant improvement in this

patient.

In Ayurveda, brain is considered to be form

of majjadhara kala9. Unsteadiness and

blurred vision are described in

majjapradosaja vikaras10. Tiktadi and

madhura drugs are indicated in

majjagatadiseases11. So Madhura-Tiktadi

drugs like Bala, Ashwagandha and

Shatavari were used to relieve unsteadiness

and vision element.

Shirodhara is beneficial for insomnia,

depression and anxiety disorders12. In this

case Shirodhara was planned to relieve

anxiety and depression due to loss of job

and some family dispute. Shirobasti is

indicated in Shirahkampa(axial tremor) and

heaviness of the head in Ayurveda13.In this

case Shirobasti was done with

Dhanvantaram oil. This oil has

vatashamaka and Brihmana properties.

Shirobasti is indicated for five to seven

days or more in shiro-rogas(diseases of the

head). Primary lesion of this disease was in

the brain. Shirobasti was given for 15 days

in this case due to chronicity of more than 2

years of this disease.

Abhyanga with Ksheerabala tail has

nourishing effect on muscles and peripheral

nerves. Patra Pinda Pottali Swedana is

effective in neuromuscular disorders and

peripheral neuropathy. Kati basti with

Panchaguna tail was done for lower back

ache. Local abhyanga and swedana on

lumbosacral region, inguinal region and

lower abdomen were administered before

each basti.

Brihat -vatachintamaṇi rasa is indicated in

all type of Vataja disorders14. Agnitundivati

helps in improvement of metabolic

activities at cellular level (agnipradipti) and

also ameliorates depleted condition of


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body. Dashamoola kwatha is useful in all

types of vataja and respiratory disorders

and has tridoṣaghna property.

Rasnaerandadi kwatha is indicated in pain

due to vata and neurological disorders15.

Ashwagandha/ Shatavari has

balya(anabolic) and

rasayana(immunomodulator) properties.

TrayodashangGuggulu/YogarajaGuggulu

is useful in all types of Vataja and

neurodegenerative disorders 16.

Significant improvement in dysarthria,

unsteady gait, axial tremors and facial

expressions were observed in this case.

Gradual improvement was noticed in every

month in this case but assessments for

scoring was done at the time of admission

and discharge every time. SARA score in

this patient was 21 before treatment which

reduced to 16, 12 and 6 after1st, 2nd and 3rd

sitting of Panchakarma. At the end of

treatment, the patient was advised

admission for Panchakarma procedures

after 3 months considering his financial

condition and requirement of therapies to

stop further worsening of symptoms. Now

the patient is under continuous follow up

for observation and treatment with stable

condition and hopes more recovery from

the disease.

This is an important outcome considering

the prognosis and non availability of

satisfactory medication. This shows that

Ayurveda may be considered of great help

for treatment of SCA patients. This

combined Ayurvedic therapy with oral

vatapittahara drugs along with Abhyanga,

PatraPindaPottali Swedana, Shirodhara,

Shirobasti, Kala basti and Matra basti may

be considered for further treatment and

research on various types of SCAs.

CONCLUSION

SCA can be managed with Ayurvedic

medicines and Panchakarma therapies.

This case study shows that SCAs patients

may be treated with satisfactory outcome

with Ayurveda. The findings may be helpful

for conducting further research work for

different types of SCAs.


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REFERENCES

1. https://www.dizziness-and-balance.com

(modified January 2016)

2. Durr A. (2010). Autosomal dominant

cerebellar ataxias: polyglutamine

expansions and beyond. Lancet Neurol,

9:885-94.

3. Schöls L, Bauer P, Schmidt T, et

al.(2004). Autosomal dominant cerebellar

ataxias: clinical features, genetics, and

pathogenesis. Lancet Neurol, 3:291-304.

4. Sriranjini SJ, Pal PK, Devidas KV,

Ganpathy S. (2009). Improvement of

balance in progressive degenerative

cerebellar ataxias after Ayurvedic therapy:

A preliminary report. Neurol India

57:166‑71.

5. Sarvesh Kumar Singh, Kshipra

Rajoria.(Jan‑Mar 2016). Ayurvedic

approach in the management of

spinocerebellar ataxia‑2: A case study.

India Ancient Science of Life / Vol 35 /

Issue 3

6. Brahmasankar M. Bhavaprakasha

Madhyakhanda. (1980). Vidyotini Hindi

commentary. 24/5‑16. 5th ed. Varanasi:

Chaukhambha Sanskrit Sansthan; p. 228.

7. Schmitz‑Hubsch T, Fimmers R,

Rakowicz M, Rola R,

ZdzienickaE,Fancellu R, et al. (2010).

Responsiveness of different rating

instruments in spinocerebellar ataxia

patients. Neurology 74:678‑84.

8. Taroni F, DiDonato S. (2004). Pathways

to motor incoordination: the inherited

ataxias. Nat Rev Neurosci Aug;5(8):641–

55. [PubMed: 15263894]

9. Aathavale AD.(1980). AstangaSangrah;

Indu commentary. Sharirsthan 5/22. Pune:

Srimada Atreya Prakashanam; p. 297.

10. Pandey GS, Sastri K.(2006). Caraka

Samhita; Vidyotini Hindi commentary.

Sutrasthan 28/17. Vol. 1. Varanasi:

Chaukumba Sanskrit Sansthana; p. 572.

11. Pandey GS, Sastri K. (2006).Caraka

Samhita; Vidyotini Hindi commentary.

Sutrasthan 28/28. Vol. 1. Varanasi:

Chaukumba Sanskrit Sansthana; p. 573.

12. Uebaba K, XuFH, Ogawa H, Tatsuse T,

Wang BH, Hisajima T, et al. (2008).

Psychoneuroimmunologic effects of

Ayurvedic oil dripping treatment, J Altern

Complement Med. 14: 1189-98 [PubMed]

13. Brahmanand T.(2004). Sarangdhar

Samhita; Dipika Hindi commentary.

Uttarakhand 11/127. Varanasi:

Chaukhamba Surbharati Prakashan; p. 410.

14. Siddhinandan M.(2007).

Bhaisajyaratnavali. Sidhiprada Hindi

commentary, 5/1095‑1097. Varanasi:


15.The Ayurvedic Formulary of India,

(2003).G.O.I., Ministry of H.F.W., ISM &

H, New Delhi, Part-I, 4:29, Pg. 61.


________________________________________________________________


16. Siddhinandan M. (2007).

Bhaisajyaratnavali. Sidhiprada Hindi

commentary, 29/157. Varanasi:



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Int J Ayu Pharm Chemijapc.com/volume9-second-issue/MNAPC-V9-I2-68-p-374-382.pdfShirodhara with ksheerabala tail (30 minutes each day) 3. Kala Basti (for 15 days) Anuvasana with Ksheerabala